When is Medical Treatment Overtreatment? Maine Doctors Take New Look

Nov 26, 2014

Medical treatment can cure illnesses and save lives. But too much treatment can cause harm, even death.

The Lown Institute in Boston estimates that between 10 and 30 percent of medical treatment in this country is unnecessary and racks up between $2 billion and $800 billion in extra costs. In Maine, some health care providers are changing their approach to ensure that they give patients what they call "right" treatment.
 

Nurse Practitioner Tom Bartol and patient Trish Farrell.
Credit Patty Wight / MPBN

About eight years ago, nurse practitioner Tom Bartol realized that some of the care he was prescribing may not benefit his patients as much as much as he thought. He was researching statins - drugs that are used to lower cholesterol and prevent heart disease.
 
"And we looked at the data and we saw a 37 percent risk reduction," Bartol says. "That's what all the guidelines are based on - this 37 percent risk reduction."

Sounds pretty good. But then Bartol wondered - what's the baseline risk for heart disease for his patients? Some on statins had a risk of between 3 and 6 percent; and when you consider those numbers, that nearly 40 percent reduction in risk doesn't sound quite as impressive.
 
"I started questioning the guidelines," Bartol says. "We have a lot of clinical guidelines we're supposed to follow. We sort of follow them like a cookbook. I was following them blindly, as I suppose many people do. They have no idea of the data behind it."

Shannon Brownlee, a former journalist who wrote a book about medical overtreatment, came to a similar conclusion 15 years ago. She was reporting on tests to detect prostate cancer. Turns out, the test catches a lot of non-lethal cancers that don't need treatment.

"And when men get treated, usually with surgery, half of them get incontinence and impotence," Brownlee says.

Brownlee says part of what drives unnecessary treatment is money: Doctors are paid per procedure or test. "And it's also what we, as patients, have come to expect. Patients think that if their doctor didn't run a lot of tests, their doctor didn't really care about them. They've come to replace technology for real care."
 

Jay Mullen, MedIcal Director of Emergency Services at MidCoast Hospital.
Credit Patty Wight / MPBN

Overuse of tests and screening tools is something that Jay Mullen is mindful of, as Medical Director of Emergency Services at MidCoast Hospital in Brunswick, "you know, because we almost never get feedback that you ordered too many CAT scans. The question usually is, why didn't you get the CAT scan?"

So Mullen has identified certain conditions with good data on effective treatment, and implemented guidelines for physicians. Say a kid falls off a swing set and hits their head. Most parents, he says, are going to want a CAT scan to make sure there's no serious brain injury.

"Nationwide, CAT scan use in kids is, between about 5 and 7 percent of ED visits end up with a CAT scan," Mullen says, "which is an astounding number, when you consider that a CAT scan has as much radiation as between 200-400 chest x-rays," which increases the risk of developing a lethal cancer later in life.

Mullen says when his physicians give their assessment to parents, they also present a written document clearly laying out proper protocol and the risks and benefits of the CAT scan. Then, they offer parents a choice.

Engaging patients and sharing data are what nurse practitioner Tom Bartol sees as key to ensuring patients get the right medical treatment.

"What we do is we treat numbers often: Your blood pressure is off, and we give you a pill to lower your blood pressure. But I say now, 'Why is your blood pressure off?' Your blood pressure is not up because you're lacking a pill. Your blood pressure is up maybe because there's stress in life. Maybe because you're overweight. Maybe because what you're eating."

Bartol now asks patients, how would you like to get off your medications? And that often provides the motivation needed to address the root cause of the health problem.

"That was the motivation," says Trish Farrell. Farrell says she was on four medications for high blood pressure and cholesterol when she started seeing Bartol about a year ago. She started exercising and changed her eating habits. Now, she's down to just one pill.
 
"Being told- you could lose five pounds if you do this - that doesn't motivate me," she says. "But knowing I could be off medication, that motivated me."

Bartol says it's not that these medications or tests are bad.  It's just that they used too often, and health care providers should present patients with data and a choice on what treatments are worth the potential benefits and potential risks.

Learn more about so-called "evidence-based" medicine.